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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 444417194
Report Date: 04/09/2025
Date Signed: 04/09/2025 04:43:55 PM

Document Has Been Signed on 04/09/2025 04:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN JOSE CC RO, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131
FACILITY NAME:BUILDING KIDZ OF SCOTTS VALLEYFACILITY NUMBER:
444417194
ADMINISTRATOR/
DIRECTOR:		MARISSA COONEY-MOOREFACILITY TYPE:
860
ADDRESS:106 VINE HILL SCHOOL ROADTELEPHONE:
(831) 438-4813
CITY:SCOTTS VALLEYSTATE: CAZIP CODE:
95066
CAPACITY: 43TOTAL ENROLLED CHILDREN: 44CENSUS: 22DATE:
04/09/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Marissa Cooney-Moore & Angelina BowersTIME VISIT/
INSPECTION COMPLETED:
04:55 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Marilou Monico and Darnella Barnes, made an unannounced Case Management Inspection. LPAs met with Site Director, Marissa Cooney-Moore, and Senior Director, Angelina Bowers. LPAs toured the facility, interviewed staff, and reviewed records.

LPAs learned from interviews that an incident that occurred on April 2, 2025 involving a child (C1) who left the playground unnoticed by staff and went to the front door located in the Sunflower Room was not reported to Licensing.

Based on records review, two staff (S3 & S4) have been working at the center and their fingerprint clearances were not associated to the facility. Senior Director a Criminal Background Clearance Transfer Request (LIC 9182) to Licensing during the inspection. A civil penalty of $1,000 was assessed for the fingerprint clearances.

LPAs observed that a teacher's assistant (S5) was alone in the Daisy Room (Toddler Option Classroom) supervising six (6) children.

As a result of this inspection, Type B deficiencies are being cited on the attached LIC 809D.

Exit interview conducted and the report was reviewed with Site Director, Marissa Cooney-Moore.

A Notice of Site Visit was issued and must remain posted for 30 days.
NAME OF LICENSING PROGRAM MANAGER: Gladys Kuizon
NAME OF LICENSING PROGRAM ANALYST: Marilou Monico
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/09/2025 04:43 PM - It Cannot Be Edited


Created By: Marilou Monico On 04/09/2025 at 02:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: BUILDING KIDZ OF SCOTTS VALLEY
FACILITY NUMBER: 444417194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
CCR
101212(d)

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Reporting Requirements - (d) Upon the occurrence, during the operation of the child care center of any of the events specified in (d)(1) below, a report shall be made to the Department by telephone or fax within the Department's next working day and during its normal business hours. In addition, a written report containing the information specified in (d)(2) below shall be submitted to the Department within seven days following the occurrence of such event.
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Site Director states that a written plan to be sent to Licensing by 04/11/25 to ensure that unusual incidents shall be reported to Licensing within the required time frame. A completed Unusual Incident Report (LIC 624) for the incident happened on 04/02/25 must be submitted to Licensing by 04/11/25.
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This requirement is not met as evidenced by:
An incident that occurred on 04/02/25 involving a child (C1) who left the playground unnoticed by staff was not reported to Licensing. This poses a potential health, safety and personal rights risk to children in care.
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Type B
04/11/2025
Section Cited
CCR101170(e)(2)

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Criminal Record Clearance - (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1596.871 shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 101170(f).
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During the inspection, Senior Director submitted a Criminal Background Clearance Transfer Request form (LIC 9182) to Licensing for the two staff to have them associated to the facility.

Deficiency corrected.
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This requirement was not met as evidenced by: Two staff (S3 & S4) fingerprint clearances were not associated to the facility. This posed a potential health, safety and personal rights risk to children in care.
Civil penalty of $1,000 was assessed.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Marilou Monico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/09/2025 04:43 PM - It Cannot Be Edited


Created By: Marilou Monico On 04/09/2025 at 02:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: BUILDING KIDZ OF SCOTTS VALLEY
FACILITY NUMBER: 444417194

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/11/2025
Section Cited
HSC
1596.955(a)(3)

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Child day care centers serving preschool age children; optional program - (a) The department shall develop guidelines and procedures to permit licensed child daycare centers serving preschool age children to create a special program component for children between 18 months to three years of age. This optional toddler program shall be subject to the following basic conditions: (3) A ratio of six children to each teacher is maintained for all children in attendance at the toddler program. An aide who is participating in on-the-job training may be substituted for a teacher when directly supervised by a fully qualified teacher.
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Site Director agreed to submit a written plan by 04/11/25 to ensure that a fully qualified infant toddler teacher will be in the classroom with a teacher's aide.
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This requirement is not met as evidenced by:
LPAs observed a teacher's assistant (S5) supervising six children in the toddler option classroom. This poses a potential health, safety and personal rights risk to children in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Gladys Kuizon
NAME OF LICENSING PROGRAM MANAGER:
Marilou Monico
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2025


LIC809 (FAS) - (06/04)
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